Treadmill exercise ameliorates ischemia-induced brain edema while suppressing Na⁺/H⁺ exchanger 1 expression.

Exercise may be one of the most effective and sound therapies for stroke; however, the mechanisms underlying the curative effects remain unclear. In this study, the effects of forced treadmill exercise with electric shock on ischemic brain edema were investigated. Wistar rats were subjected to transient (90 min) middle cerebral artery occlusion (tMCAO). Eighty nine rats with substantially large ischemic lesions were evaluated using magnetic resonance imaging (MRI) and were randomly assigned to exercise and non-exercise groups. The rats were forced to run at 4-6m/s for 10 min/day on days 2, 3 and 4. Brain edema was measured on day 5 by MRI, histochemical staining of brain sections and tissue water content determination (n=7, each experiment). Motor function in some rats was examined on day 30 (n=6). Exercise reduced brain edema (P<0.05-0.001, varied by the methods) and ameliorated motor function (P<0.05). The anti-glucocorticoid mifepristone or the anti-mineralocorticoid spironolactone abolished these effects, but orally administered corticosterone mimicked the ameliorating effects of exercise. Exercise prevented the ischemia-induced expression of mRNA encoding aquaporin 4 (AQP4) and Na(+)/H(+) exchangers (NHEs) (n=5 or 7, P<0.01). Microglia and NG2 glia expressed NHE1 in the peri-ischemic region of rat brains and also in mixed glial cultures. Corticosterone at ~10nM reduced NHE1 and AQP4 expression in mixed glial and pure microglial cultures. Dexamethasone and aldosterone at 10nM did not significantly alter NHE1 and AQP4 expression. Exposure to a NHE inhibitor caused shrinkage of microglial cells. These results suggest that the stressful short-period and slow-paced treadmill exercise suppressed NHE1 and AQP4 expression resulting in the amelioration of brain edema at least partly via the moderate increase in plasma corticosterone levels.

The development of a measure of motivational changes following acquired brain injury.

Motivational deficits following acquired brain injury have been found to be both prevalent and particularly disabling. Despite this, relatively little attention has been given to such deficits. The development of self and informant versions of a new questionnaire measure of the changes in motivation that may occur following acquired brain injury is described. The measure demonstrates excellent psychometric properties including high test-retest (r = .90) and split-half reliability (.94), high internal consistency (Cronbach's alpha = .94), and good concurrent validity. The study also demonstrates that the questionnaire is measuring a different domain to cognitive tests and tests of affect, but one that is predictive of brain injury outcome. There was moderate overlap between self-report and relative versions of the questionnaire (r = .41) but results suggest that the relative version has the stronger predictive value. The potential uses of the measure in relation to theory and practice are discussed.

Exercise pre-conditioning strengthens brain microvascular integrity in a rat stroke model.

Increasing evidence indicates that physical activity reduces brain damage after stroke. The purpose of this study was to determine whether exercise-induced neuroprotection is associated with improved brain integrity in stroke. Adult male Sprague-Dawley rats (3 months old, n=38) exercised on a treadmill, which required repetitive locomotor movement, for 30 minutes each day for 3 weeks. Then, using an intraluminal filament, stroke was induced by either 2 hours middle cerebral artery (MCA) occlusion followed by 24 or 48 hours of reperfusion. Brain damage was determined by evaluating brain infarction and brain edema, as well as ultrastructural alteration in endothelial-matrix-astrocyte interfaces.Pre-ischemic motor exercise significantly (p<0.01) reduced infarct volume in the frontoparietal cortex and the dorsolateral striatum by 79%. By comparing the percentage difference in brain volume between the right (stroke site) and left hemispheres, we demonstrated a significant (p<0.01) reduction in brain edema associated with reduced infarct volume in a 3 week exercise group (Group 1, n=10) and a 3 week exercise plus 3 week rest group (Group 2, n=10). Edema in cortex and striatum was 19 +/- 4% without exercise pre-conditioning (n=10), in contrast to 5 +/- 3% (Group 1) or 6 +/- 4% (Group 2). The thickness of the basal lamina was enhanced by exercise. In ischemic rats without pre-exercise, alterations in microvessel ultrastructure with decreased luminal area, parenchymal edema and swollen astrocyte end-feet, as well as an abnormally thin basal lamina were observed. In contrast, exercise pre-conditioning significantly reduced the ischemic alterations, decreasing brain edema and increasing basal lamina thickness. This study suggests that exercise pre-conditioning reduces brain injury by decreasing cerebral permeability and enhancing brain integrity after stroke. This exercise-induced endogenous neuroprotection could be an effective strategy to ameliorate ischemic brain injury from stroke.

Blood pressure and functional recovery in acute ischemic stroke.

BACKGROUND AND PURPOSE: The relevance of elevated blood pressure in acute ischemic stroke and its most appropriate management are unresolved. We aimed to evaluate the rate of functional recovery with relation to early blood pressure management in patients with ischemic stroke. METHODS: Four hundred eighty-one consecutive ischemic stroke patients were admitted to the Neurology Service within 20.9+/-10.5 hours of symptoms onset as part of the Barcelona Downtown Stroke Registry, including 235 patients who received oral antihypertensive agents within <24 hours after stroke onset. Demographic, clinical (Mathew scale), and CT scan findings were collected prospectively. Mean arterial pressure (MAP) was recorded before hospital arrival and at 7 AM on days 1, 2, and 7 of hospitalization. The primary end point was complete functional recovery at day 7 defined as a score of 0 to 1 on the modified Rankin scale. RESULTS: Two hundred fifty-two patients achieved complete recovery on day 7. Using logistic regression, independent predictors of complete recovery included mild impairment at stroke presentation, lack of history of hypertension, and absence of brain edema on CT scan. Also, a 20% to 30% drop in MAP on day 2 after stroke onset almost tripled the odds of full recovery (odds ratio, 2.9; 95% CI, 1.3 to 6.3). MAP tended to normalize after stroke in all subjects, more rapidly if hypotensive agents were administered. Brain edema was also less frequent in patients with a greater drop in blood pressure. Despite the fact that a drop in MAP >30% from baseline was observed in 49 patients, this preceded worsening stroke in only 4 patients. Conversely, worsening stroke occurred in 51 patients despite stable blood pressure. CONCLUSIONS: These results suggest that complete recovery in ischemic stroke is facilitated by a moderate blood pressure reduction when brain edema develops, most likely as the result of a more adequate cerebral perfusion pressure. Conversely, stroke worsening due to pharmacological hypoperfusion is exceptional.

Early hemicraniectomy in patients with complete middle cerebral artery infarction.

BACKGROUND AND PURPOSE: Malignant, space-occupying supratentorial ischemic stroke is characterized by a mortality rate of up to 80%. Several reports indicate a beneficial effect of hemicraniectomy in this situation. However, whether and when decompressive surgery is indicated in these patients is still a matter of debate. METHODS: In an open, prospective trial we performed hemicraniectomy in 63 patients with acute complete middle cerebral artery infarction. Initial clinical presentation was assessed by the Scandinavian Stroke Scale (SSS) and the Glasgow Coma Scale (GCS). All survivors were reexamined 3 months after surgical decompression, with the clinical evaluation graded according to the Rankin Scale (RS) and Barthel Index (BI). We analyzed the influence of early decompressive surgery (<24 hours after symptom onset, based on clinical status at admission and initial CT findings) versus late surgery (>24 hours after first reversible signs of herniation) on mortality, functional outcome, and the length of time of critical care therapy was needed. RESULTS: In total, 46 patients (73%) survived. Despite complete hemispheric infarction, no survivor suffered from complete hemiplegia or was permanently wheelchair bound. In patients with speech-dominant hemispheric infarction (n=11), only mild to moderate aphasia was present. The mean BI score was 65, and RS score revealed severe handicap in 13% of the patients. In 31 patients with early decompressive surgery, mortality was 16% and BI score 68.8. Early hemicraniectomy led to a significant reduction in the length of time critical care therapy was needed (7.4 versus 13.3 days, P<0.05). CONCLUSIONS: In general, the outcome of patients treated with craniectomy in severe ischemic hemispheric infarction was surprisingly good. In addition, early decompressive surgery may further improve outcome in these patients.

Traumatismo Craneoencefálico: Enfoque para Atención en Urgencias / Craneoencephalic traumatism

La atención del paciente en traumatismo craneoencefálico en el servicio de urgencias, requiere de una evaluación integral para determinar si se trata de un traumatismo craneoencefálico aislado o hay lesiones asociadas que deben ser identificadas y tratadas rápidamente si comprometen la vida del paciente. Debe evitarse la hipoxia, la hipotensión y la anemia para garantizar una presión de perfusión cerebral adecuada; ésta es la función primordial de la atención en urgencias. Desde el punto de vista patológico hay dos tipos de lesiones: Las debidas al efecto inmediato del impacto conocidas como daño primario, dentro de las cuales están las lesiones del cuero cabelludo, las fracturas de cráneo, contusión, laceración, conmoción cerebral y lesió axonal difusa; las debidas a efectos tardíos del traumatismo craneoencefálico conocidas como daño secundario, dentro de las cuales están hemorragia subaracnoidea, hematoma epidural, subdural e intraparenquimatoso, edema cerebral, aumento de presión intracraneana, daño cerebral hipóxico e infección. El diagnóstico de varias de estas lesiones se basa en el estudio de la escanografía cerebral simple. Hay pacientes que requieren tratamiento quirúrgico (hematomas epidural, subdural, intraparenquimatoso, fracturas deprimidas abiertas y cerradas, aunque éstas últimas están en discusión); los pacientes con traumatismo craneoencefálico que no requieren tratamiento quirúrgico se enfocan de acuerdo a la clasificación en: Leve que deben tenerse en observación; moderado que requieren hospitalización, medidas antiedema, mantenimiento de la perfusión cerebral; severo que deben tratarse con intubación, atención en unidades de cuidado intensivo y monitoreo de presión intracraneana

Computerized tomography and prognosis in paediatric head injury.

The authors have analysed the computerized tomography (CT) findings and their correlation with the clinical state, early and late outcome in children and adolescents with head injuries (HI). This study represents clinical and CT data of 82 consecutive HI patients under 18 years of age. Among them 51 (62%) were boys and 31 (38%) girls. The application of CT to the evaluation of the morphologic manifestations of HI in children has shown some differences in forms and mechanisms of injury and in outcome compared to adults. In the paediatric HI the most frequent finding was diffuse brain swelling with CT evidence of ventricular and cisternal compression or obliteration. Prognostically the most unfavourable findings were shearing injury, intracerebral and subdural haematomas combined with brain swelling and parenchymal damage. According to the Lidcombe impairment scale, outcome from severe paediatric HI was determined in the 3rd and 6th months, one year and 2 years after the injury. The outcome two years after severe HI varied to a great extent and was better in children than in adults. Although there was long-term disruption of the patient's quality of life, our data show that as there are no predictors of individual outcomes in child HI, no child should be excluded from early and long-term rehabilitation.

[Symptomatic acoustic hallucinations after traumatic brain damage. Review of the literature and case report]. / Symptomatische akustische Halluzinose nach traumatischer Hirnschädigung. Literaturübersicht und Fallbericht.

Symptomatic hallucinosis can be observed after subcortical lesions of different localisation with a predominance of complex-visual perceptive disturbances. Only single cases with complex acoustic hallucinosis have been reported in the literature. A 30-year-old patient is presented who suffered from a midbrain syndrome after severe traumatic brain injury and developed an acoustic hallucinosis in the chronic stage of rehabilitation. The functional relevance and therapeutic strategies are considered with regard to the relevant literature.

[Craniocerebral trauma caused by sports. Pathogenic mechanism, clinical aspects and physical therapy with special reference to manual lymph drainage]. / Schädel-Hirn-Traumen durch Sport. Pathomechanismen, Klinik und physikalische Therapie unter besonderer Berücksichtigung der manuellen Lymphdrainage.

On top of one comprehensive English accident statistics of head injuries in sports there is riding, followed by rugby and football. In Germany there is not very little of head and brain damage due to football as wide spread sports, followed by riding, athletics and gymnastics, whereas in boxing recurring head injuries of dosage underlaying concussion of the brain do play a part even in spite of wearing boxing caps. Anyway, damage of the brain will always be the most heavy complication. Besides uncomplicated wounds of the soft parts such as wounds of the scalp or contusion of the face the closed skull and brain damage will be the most generally form of head injury in sports, followed by fractures of the skull with contusion of the brain and intracranial hemorrhage. In the treatment of the post-concussion and post-contusion syndrome manual lymph drainage will achieve more importance by its anti-edematous and therefore depressant and also sedative effects.

[Advances in the conservative treatment of acute traumatic cerebral edema. Controlled clinical trial with follow-up examination (author's transl)]. / Fortschritte bei der konservativen Behandlung des akuten traumatischen Hirnödems. Kontrollierte klinische Studie mit Nachuntersuchung.

Studies in 142 accident victims with severe craniocerebral trauma showed that the intravenous application of sodium escinate over several days considerably reduced the dangerous rise in intracranial pressure and also the total mortality in comparison with corticosteroid therapy alone. Both groups, each of 71 patients, were adjusted from an initial intraventricular pressure of 500--250 mm H2O to the same basic pressure of 150 mm H2O hydrostatically. In the same way, sodium escinate shortened the duration of unconsciousness. The renal function in patients was good. Follow-up examinations at least 2 to a maximum of 3.5 years after the accident and treatment showed a significantly higher rehabilitation rate in the sodium escinate group.